Leadership is a hot topic in nursing. We recognize the importance of leaders who represent us well to those outside of the profession, yet many nurses who practice at the bedside do not think about displaying leader-like behavior because they do not view themselves as "leaders." This is unfortunate, because real leadership is less about a title or institutionally granted power, and more about how we "show up" in the myriad of moments that make up our days. The broader image of the nursing profession is formed in the many day-to-day interactions between nurses and patients, families, the public, physicians, and administrators. Nursing leaders are those who can find their inner leader and use the moments of their days to provide the best patient care, at whatever level of the organization they contribute.
Leadership as a field of study is at a similar crossroad. There is a growing consensus in the leadership literature that "everyone at every level is now expected to lead."1 In her soon to be published textbook on leadership, McKee1 writes "we will emphasize that everyone is a leader-or can become a leader, if he or she chooses." Leaders and leadership faculty in business schools, healthcare administration courses, and organizational development programs agree that this change in our conception of leaders requires a shift in how leadership is taught and developed. We have written this article to add to the growing literature on how to develop leadership skills. There are numerous theories that provide methodologies for how to think about leadership from this perspective including Hersey and Blanchard's Situational Leadership,2 Covey's Principle-Centered Leadership,3 and Kouzes' and Posner's Five Practices of Exemplary Leadership.4 All of these theories, along with the concepts of Emotional Intelligence advanced by Goleman,5 have been influential in developing our understanding of leadership in healthcare. However, the process by which one develops leadership behaviors and begins to be seen as a leader is much more complex than simply reading a book or attending a leadership development course. It is also important to hear from leaders how they develop their skills.
Throughout our respective careers, as a nursing leader (P.G.) and an organizational psychologist (B.T.), we have come to know the importance of seeing every person as having "a leader within" that can be accessed and that leadership is an "in the moment" experience. Our work has focused on helping people to find that leader within and to develop the behaviors that will show their leadership to others. Over the past few years, we have identified the following 5 "skill-cepts" (skills derived from leadership concepts) as essential to leading and have been introducing them to people around us:
1. Know your stuff
2. Have a goal
3. Stay "in role"
4. Love the fight
5. Cultivate gratitude
Practicing these skill-cepts will help the development of any leader, regardless of the structural theory used in defining leadership work. The remainder of this article will explain how to practice these skill-cepts and find your leader within.
KNOW YOUR STUFF
The first requirement is to be confident in what you know. Knowledge is essential to any profession. It is the core of our contribution to the world. It is hard to take your place at the table without the content knowledge and expertise to contribute. However, knowledge is just the beginning. We must also have confidence to "know what we know." It takes a certain level of energy to engage others and put our knowledge out there. Confidence is like a battery that can supply that energy. Nurses who really know their clinical practice area and have expertise or special skills are highly valuable to patients, families, and other team members. They are respected for their contributions, and when they speak, others listen. This is why advancing education levels and certification are so valued in developing a high quality nursing staff and obtaining Magnet designation. Perinatal nurses can cultivate their confidence through developing their expertise in their specialty area, whether that is neonatal intensive care, mother-baby nursing, or labor and delivery. Knowing how to interpret a woman's progress through labor, or signs of trouble in a newborn are a source of confidence. But the nurse must believe in his or her knowledge to use it effectively. This is the essence of confidence, "believing in what you know."
HAVE A GOAL
It is hard to lead when you do not know where you are going. Meeting the moments in our lives with intention is essential to moving any agenda forward. The key is to know the direction you want to head in-your goal. Before entering any situation, take a silent moment to answer the question, "What is my goal here?" This helps you focus on where you want to end up. Being clear on your goal for an interaction is fundamental to any leadership plan.
STAY "IN ROLE"
The third skill-cept is the ability to stay grounded. This is essential to maintaining our focus on our goal and our ability to put forth what we know. We call this "staying in role." When we are in role we stay focused on the situation and our goal. When we take things personally, we become focused on "me." When we are "in person," we "be" in the world. Whatever we feel is who we are in that moment, so being "in person" can be an emotional roller coaster. If something negative happens our feelings get hurt, we get angry or we feel attacked. If something positive happens, we are happy, and we enjoy the feeling. In either case, we assume that what is happening proves something about us.
When we are "in role," we "do." Our focus is on our goals and how to achieve them. When we are "in role," we do not leave our personalities behind. We infuse how we are "in role" with the best of who we are as people. If we take up our role without informing it with who we are, we can come across as wooden and will be less effective. Staying "in role" allows us to see each piece of information, positive or negative, as another puzzle piece bringing us closer to seeing the whole picture and knowing how to achieve or modify our goal. When we are "in role," negative experiences provide information we use to redirect toward our goals. Similarly, if something goes well, we understand that the strategies we are using are working.
Consider the following examples:
A mother has a teenage son who is angry because she will not let him use the family car after 10 PM on the weekend. If she takes her son's anger personally, the interaction will most likely turn into a screaming match, or the mother may cave in to his request. When the mother stays "in role," she is able to draw on her knowledge that her son's rebellion and anger are normal developmental responses part of his attempt to establish his separateness and adulthood. She focuses on her goals of keeping her son safe, while developing his independence. As a result, she might negotiate an 11 PM curfew for a specific supervised school event, or she might stick with her original limit, depending on his past behavior.
Here's an example from nursing that brings together the first three skill-cepts
A nurse is working with a physician who becomes irate when a piece of equipment to complete a procedure on a patient is missing from the room. If she takes it personally, she might become angry and yell back, or leave the room in a huff. Staying "in role," with the goal of caring for the patient, the nurse could interpret the physician's behavior as a reflection of his anxiety about the patient outcome, so she may decide to ignore the verbal aggression and use her knowledge of the hospital's systems to get the equipment as quickly as possible. If the physician continues to berate her, staying "in role," she might choose to set some limits with the physician by saying something like "I am sorry that this has happened. I know how the equipment is managed and I can to get you what you need. Your yelling at me will not make it get here faster, and it is actually making it hard for me to talk to the materials department." This nurse has responded "in role," stays focused on her goal and uses her knowledge of the hospital system to resolve the situation. She shares what she knows with confidence and acknowledges her colleague's frustration, but does not allow herself to lapse into "person" and yell back. If the physician continues to be abusive, she might set an even more explicit boundary by saying that she will not tolerate being yelled at and if it does not stop immediately, she will request assistance from the manager so she can leave the room (provided this would not place the patient in jeopardy).
The final 2 skill-cepts focus on developing an attitude toward events that are seemingly negative-the first has to do with how we view resistance and the second with how we handle things that seem to not go our way.
LOVE THE FIGHT
Whenever we take up a leadership role, we are bound at one time or another to encounter people who resist our leadership. This leadership skill-cept is counter-intuitive, but when we are trying to promote a change, be it in a physician's attitude or a staff schedule, the existence of resistance is a powerful signal that the change is having an impact. Resistance can manifest as angry outbursts, silent churning, complaining, rebellion, blaming, and often passive resistance. Astute leaders recognize this resistance as a positive sign that their initiative is having an impact.
Listening carefully to the information contained in the resistance can provide leaders with crucial information about how to keep the momentum of the change going. For example: A nurse manager is implementing a new staffing model in the NICU. Staff helped design a model that requires nurses to work in smaller groups within the larger unit, and to be assigned a specific group of patients to care for from admission to discharge. Many staff like this model because they see the benefits of continuity of care for the patients. Others are angry that they will be "stuck" in their pod with the same people and patients for a long period of time. These people really valued the variety of experiences that came from working across the entire NICU.
The manager who takes the angry statements personally might see those staff as obstructionists, censure them, or try to convince them of the benefits of the new model. Staying in role, the manager recognizes that both groups, the ones in favor and the angry staff, are positive signs about the implementation of the change. She knows that the numbers of staff who support the plan are a signal that the change itself is proceeding well. She also knows that those who are complaining about the change are attempting to bring out important information. She may not appreciate how they are doing this, but she realizes that the information is crucial to developing "an even better" staffing plan. When she listens carefully, she hears a desire to maintain expertise with all types of patients; some of them are now grouped into a particular area of the unit. She also hears that when a pod is short staffed, other teams' members will need to float into those areas, but may lack the skills needed to care for the more specialized populations if not exposed to them on a regular basis. She also hears that if a nurse gets "stuck" with a particularly difficult patient, she could be "stuck" for a long period of time. Notice that each concern has merit and that attending to each will provide an even more effective staffing pattern. In this situation, the manager took the concerns back to the task force, which revised the model. The task force developed a rotation plan that allows nurses who desire exposure to different populations to do a month in each specialty pod twice a year. This ensures that a cadre of very flexible staff are available to help cover for absence and makes the new model even better. The angry staff become less upset as their concerns are taken seriously and resolved. The manager was clear with these folks that their issues would be addressed, and that the anger had to deescalate. A passion to continuously improve the new model replaced the anger and resentment.
Cultivating gratitude means committing yourself to using challenges as information about meeting your goals. Cultivating gratitude helps us prepare to be open and learn from our experiences. A gratitude mindset is an antidote to bitterness, anger, and depression-the energy drainers of life. Focusing on what we can be grateful for keeps us away from any semblance of victim mentality. We become aware that there is always something positive to gain from even the most difficult experience.
This principle is one that is challenging for most nurses. From early in our education and careers, we are imprinted with the notion of the hierarchy within healthcare systems.
This unfortunate paradigm has affected our interactions with everyone around us. How often have you heard a colleague say, "I'm just a staff nurse?" The speaker immediately places herself as one down from the other roles in the situation. Another common effect of this hierarchical thinking is that a nurse uses her sense of being a victim of physicians to create a sense of entitlement to special support and assistance. It does not create a sense of self-agency or empowerment. It is often the root of tensions that exist between nurses and those who work in other departments such as the pharmacy and laboratory. It also may cause nurses to treat hospital administrators as enemies, rather than as strategic partners who can help them build the ideal systems for patient care.
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Counteracting victim thinking starts with each individual. If unpleasant things happen to us, or things do not go our way, we need to cultivate a different way of thinking. Our approach to this is gratitude. Even in the worst of circumstances-the death of someone close, loss of a job, or someone being angry about a mistake we have made-we have learned that remembering all the positive things we have to be grateful for helps to stay out of victim mode.
Once we regain equilibrium through that exercise, we move on to figuring out the learning opportunities in the current situation. It may take weeks, months, or years to understand how we were shaped and grew from a negative experience, but in every case the learning can be found. Most of the learning is very personal, but in the end it provides more confidence and experience so that we are able to handle the next challenging situation better.
These 5 skill-cepts are the foundations for effective leadership in every role we play in life. Being grounded in what you know, clear on your goals or vision, not taking things personally, and using the natural resistance to change to help you. Wrap it all up in an attitude of gratitude and you become someone others want to be around and follow because you convey a positive message about the future. This will help you to be recognized as a leader, regardless of your position in the organization. In fact, being a leader is basically about constantly trying to be a better person. We all have leaders within us. If you do not think of yourself as a leader yet, we encourage you to embrace the journey to find that leader within. If you are a nursing leader today, we hope you find these skill-cepts useful in your personal journey to being an even better leader-because it is critical to ensuring we provide the best patient care, and is essential to making our healthcare system safer and more reliable.